Provider Demographics
NPI:1902101934
Name:TIBKE, JILL (NP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:TIBKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:SUITE G600
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-9449
Mailing Address - Fax:913-945-7453
Practice Address - Street 1:19550 E 39TH ST S
Practice Address - Street 2:STE. 210
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2303
Practice Address - Country:US
Practice Address - Phone:816-478-9071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-23
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2001023168363LA2200X
KS53-75056-031363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4364019Medicare PIN